Publications, Data, & Statistics

Reports, recommendations, and other studies can be important resources for investigating and preventing waterborne disease outbreaks. Below are a list of published documents that focus on recreational water illnesses, organized by topic area. These documents appear in the Morbidity and Mortality Weekly Report (MMWR), Emerging Infectious Diseases (EID), Eurosurveillance, and other open-access publications.

Publication Highlight

Hlavsa MC, Aluko SK, Miller AD, Person J, Gerdes ME, Lee S, Laco JP, Hannapel EJ, and Hill VR. Outbreaks Associated with Treated Recreational Water — United States, 2015–2019. MMWR Morb Mortal Wkly Rep 2021;70(20):733–738. DOI: https://www.cdc.gov/mmwr/volumes/70/wr/mm7020a1.htm?s_cid=mm7020a1_w.

Publications

Listed below are reports of swimming-related disease outbreaks, swimming safety, and pool operation.

Hlavsa MC, Aluko SK, Miller AD, Person J, Gerdes ME, Lee S, Laco JP, Hannapel EJ, and Hill VR. Outbreaks Associated with Treated Recreational Water — United States, 2015–2019. MMWR Morb Mortal Wkly Rep 2021;70(20):733–738. DOI: https://www.cdc.gov/mmwr/volumes/70/wr/mm7020a1.htm?s_cid=mm7020a1_w.
Vanden Esschert KL, Mattioli MC, Hilborn ED, et al. Outbreaks Associated with Untreated Recreational Water — California, Maine, and Minnesota, 2018–2019. MMWR Morb Mortal Wkly Rep 2020;69:781–783. DOI: http://dx.doi.org/10.15585/mmwr.mm6925a3.

These commentaries were written to inform public health and healthcare professionals and aquatics staff about the need for action on building and supporting recreational water illness (RWI) prevention plans.

Listed below are reports covering diarrhea-related topics, including disease outbreaks, swimming safety, and pool operation.

Zlot A, Simckes M, Vines J, Reynolds L, Sullivan A, Scott M, McLuckie JM, Kromer D, Hill VR, Yoder JS, Hlavsa MC. Norovirus outbreak associated with a natural lake used for recreation – Oregon, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(18):485-90.
Hilborn ED, Roberts VA, Backer LC, DeConno E, Egan JS, Hyde JB, Nicholas DC, Wiegert EJ, Billing LM, DiOrio M, Mohr MC, Hardy FJ, Wade TJ, Yoder JS, Hlavsa MC. Algal bloom–associated disease outbreaks among users of freshwater lakes — United States, 2009–2010. MMWR Morb Mortal Wkly Rep. 2014;63(01):11-15.
CDC. Promotion of healthy swimming after a statewide outbreak of cryptosporidiosis associated with recreational water venues — Utah, 2008–2009. MMWR Morb Mortal Wkly Rep. 2012;61(19):348-52.
CDC. Outbreak of cryptosporidiosis associated with a splash park — Idaho, 2007. MMWR Morb Mortal Wkly Rep. 2009:58(22):615-8.
CDC. Communitywide cryptosporidiosis outbreak — Utah, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(36):989-93.
CDC. Cryptosporidiosis outbreaks associated with recreational water use — five states, 2006. MMWR Morb Mortal Wkly Rep. 2007;56(29):729-32.
CDC. An outbreak of norovirus gastroenteritis at a swimming club — Vermont, 2004. MMWR Morb Mortal Wkly Rep. 2004;53(34):793-5.
CDC. Public health consequences and outbreak management for “Norwalk-like viruses.” MMWR Morb Mortal Wkly Rep. 2001;50(RR-9):1-18.
CDC. Shigellosis outbreak associated with an unchlorinated fill-and-drain-wading pool — Iowa, 2001. MMWR Morb Mortal Wkly Rep. 2001;50(37):797-800.
CDC. Protracted outbreaks of cryptosporidiosis associated with swimming pool use — Ohio and Nebraska, 2000. MMWR Morb Mortal Wkly Rep. 2001;50(20):406-10.
CDC. Outbreak of gastroenteritis associated with an interactive water fountain at a beachside park — Florida, 1999. MMWR Morb Mortal Wkly Rep. 2000;49(25):565-8.
CDC. Outbreak of cryptosporidiosis associated with a water sprinkler fountain — Minnesota, 1997. MMWR Morb Mortal Wkly Rep. 1998;47(40):856-60.
CDC. Lake-associated outbreak of Escherichia coli O157:H7 — Illinois, 1995. MMWR Morb Mortal Wkly Rep. 1996;45(21):437-9.
CDC. Cryptosporidium infections associated with swimming pools — Dane County, Wisconsin, 1993. MMWR Morb Mortal Wkly Rep. 1994;43(31):561-3.
CDC. Epidemiologic notes and reports swimming-associated cryptosporidiosis — Los Angeles County. MMWR Morb Mortal Wkly Rep. 1990;39(20):343-5.
CDC. Gastrointestinal illness among scuba divers — New York City. MMWR Morb Mortal Wkly Rep. 1983;32(44):576-7.

Listed below are reports related to skin, ear, and eye illnesses, including disease outbreaks, swimming safety, and pool operation.

Wilken JA, DiMaggio M, Kaufmann M, O’Connor K, Smorodinsky, S, Armatas C, Barreau T, Kreutzer R, Ancheta L. Inhalational chlorine injuries at public aquatic venues — California, 2008–2015. MMWR Morb Mortal Wkly Rep. 2017;66:498–501.
Hilborn ED, Roberts VA, Backer LC, DeConno E, Egan JS, Hyde JB, Nicholas DC, Wiegert EJ, Billing LM, DiOrio M, Mohr MC, Hardy FJ, Wade TJ, Yoder JS, Hlavsa MC. Algal bloom–associated disease outbreaks among users of freshwater lakes — United States, 2009–2010. MMWR Morb Mortal Wkly Rep. 2014;63(01):11-15.
CDC. Estimated burden of acute otitis externa — United States, 2003–2007. MMWR Morb Mortal Wkly Rep. Morb Mortal Wkly Rep. 2011;60(19):605-9.
CDC. Respiratory and ocular symptoms among employees of a hotel indoor waterpark resort — Ohio, 2007. MMWR Morb Mortal Wkly Rep. 2009;58(04):81-5.
Chen L, Dang B, Mueller C, Dunn KH, Almaguer D, Ernst JL, Otto III CS. Health hazard evaluation report: Investigation of employee symptoms at an indoor waterpark — Ohio, 2007. [PDF – 64 pages] National Institute for Occupational Safety and Health. 2008; June: HETA 2007-0163-3062.
Sopoh GE, Johnson RC, Chauty A, Dossou AD, Aguiar J, Salmon O, Portaels F, Asiedu K. Buruli ulcer surveillance, Benin, 2003-2005. [PDF – 3 pages]. Emerg Infect Dis. 2007;13(9):1374-6.
Edson RS, Terrell CL, Brutinel WM, Wegenack NL. Mycobacterium intermedium granulomatous dermatitis from hot tub exposure. Emerg Infect Dis. 2006;12(5):821-3.
Vugia DJ. Jang Y, Zizek C, Ely J, Winthrop KL, Desmond E. Mycobacteria in nail salon whirlpool footbaths, California. Emerg Infect Dis. 2005;11(4):616-8.
CDC. Pseudomonas dermatitis/folliculitis associated with pools and hot tubs — Colorado and Maine, 1999-2000. MMWR Morb Mortal Wkly Rep. 2000;49(48): 1087-91.
CDC. Outbreak of pharyngoconjunctival fever at a summer camp — North Carolina, 1991. MMWR Morb Mortal Wkly Rep. 1992;41(19):342-4.
CDC. Cercarial dermatitis outbreak at a state park — Delaware, 1991. MMWR Morb Mortal Wkly Rep. 1992;41(14):225-8.
CDC. An outbreak of Pseudomonas folliculitis associated with a waterslide — Utah. MMWR Morb Mortal Wkly Rep. 1983;32(32):425-7.
CDC. Staphylococcal infections among river guides — Tennessee, South Carolina, and North Carolina. MMWR Morb Mortal Wkly Rep. 1982;31(45):605-7.
CDC. Otitis due to Pseudomonas aeruginosa serotype 0:10 associated with a mobile Redwood hot tub system — North Carolina. MMWR Morb Mortal Wkly Rep. 1982;31(40):541.
CDC. Cercarial dermatitis among bathers in California: Katayama Syndrome among travelers to Ethiopia. MMWR Morb Mortal Wkly Rep. 1982;31(32):435-8.

Listed below are reports related to respiratory illnesses, including disease outbreaks, swimming safety, and pool operation.

Wilken JA, DiMaggio M, Kaufmann M, O’Connor K, Smorodinsky, S, Armatas C, Barreau T, Kreutzer R, Ancheta L. Inhalational chlorine injuries at public aquatic venues — California, 2008–2015. MMWR Morb Mortal Wkly Rep. 2017;66:498–501.
Hilborn ED, Roberts VA, Backer LC, DeConno E, Egan JS, Hyde JB, Nicholas DC, Wiegert EJ, Billing LM, DiOrio M, Mohr MC, Hardy FJ, Wade TJ, Yoder JS, Hlavsa MC. Algal bloom–associated disease outbreaks among users of freshwater lakes — United States, 2009–2010. MMWR Morb Mortal Wkly Rep. 2014;63(01):11-15.
CDC. Legionellosis — United States, 2000–2009. MMWR Morb Mortal Wkly Rep. 2011;60(32):1083-6.
Weisel CP, Richardson SD, Nemery B, Aggazzotti G, Baraldi E, Blatchley III ER, Blount BC, Carlsen KH, Eggleston PA, Frimmel FH, Goodman M, Gordon G, Grinshpun SA, Heederik D, Kogevinas M, LaKind JS, Nieuwenhuijsen MJ, Piper FC, Sattar SA. Childhood asthma and environmental exposures at swimming pools: state of the science and research recommendations. Environ. Health Perspect. 2009;(4):500-7.
CDC. Respiratory and ocular symptoms among employees of a hotel indoor waterpark resort — Ohio, 2007. MMWR Morb Mortal Wkly Rep. 2009;58(04):81-5.
CDC. Illness associated with red tide — Nassau County, Florida, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(26): 717-20.
Chen L, Dang B, Mueller C, Dunn KH, Almaguer D, Ernst JL, Otto III CS. Health hazard evaluation report: Investigation of employee symptoms at an indoor waterpark — Ohio, 2007. [PDF – 64 pages] National Institute for Occupational Safety and Health. 2008; June: HETA 2007-0163-3062.
CDC. Surveillance for travel-associated Legionnaires Disease — United States, 2005-2006. MMWR Morb Mortal Wkly Rep. 2007;56(48):1261-3.
CDC. Cruise-ship-associated Legionnaires Disease, November 2003-May 2004. MMWR Morb Mortal Wkly Rep. 2005;54(45):1153-5.
Falkinham, J. Mycobacterial aerosols and respiratory disease. Emerg Infect Dis. 2003;9(7):763-7.
Graham, DR. Hot-tub–associated mycobacterial infections in immunosuppressed persons. Emerg Infect Dis. 2002;8(7):750.
Mangione, EJ, Huitt G, Lenaway D, Beebe J, Bailey A, Figoski M, Rau MP, Albrecht KD, Yakrus MA. Nontuberculous mycobacterial disease following hot tub exposure. Emerg Infect Dis. 2001;7(6):1039-42.
Fredricks D, Jolley JA, Lepp PW, Kosek JC, Relman DA. Rhinosporidium seeberi: A human pathogen from a novel group of aquatic protistan parasites. Emerging Infect Dis. 2000;6(3):273-82.
CDC. Legionnaires Disease associated with a whirlpool spa display — Virginia, September – October, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(04):83-6.
CDC. Update: Outbreak of Legionnaires’ Disease associated with a cruise ship, 1994. MMWR Morb Mortal Wkly Rep. 1994;43(31):574.
CDC. Outbreak of pneumonia associated with a cruise ship, 1994. MMWR Morb Mortal Wkly Rep. 1994;43(28):521.
CDC. Outbreak of pharyngoconjunctival fever at a summer camp — North Carolina, 1991. MMWR Morb Mortal Wkly Rep. 1992;41(19):342-4.

Listed below are reports related to neurologic illnesses, including disease outbreaks, swimming safety, and pool operation.

Hilborn ED, Roberts VA, Backer LC, DeConno E, Egan JS, Hyde JB, Nicholas DC, Wiegert EJ, Billing LM, DiOrio M, Mohr MC, Hardy FJ, Wade TJ, Yoder JS, Hlavsa MC. Algal bloom–associated disease outbreaks among users of freshwater lakes — United States, 2009–2010. MMWR Morb Mortal Wkly Rep. 2014;63(01):11-15.
CDC. Primary Amebic Meningoencephalitis — Arizona, Florida, and Texas, 2007. MMWR Morb Mortal Wkly Rep. 2008;57(21):573-7.
CDC. Aseptic meningitis outbreak associated with Echovirus 9 among recreational vehicle campers — Connecticut, 2003. MMWR Morb Mortal Wkly Rep. 2004;53(31):710-13.
CDC. Primary Amebic Meningoencephalitis — Georgia, 2002. MMWR Morb Mortal Wkly Rep. 2003;52(40):962-4.
CDC. Primary Amebic Meningoencephalitis — North Carolina, 1991. MMWR Morb Mortal Wkly Rep. 1992;41(25):437-40.

Listed below are reports related to wound infections, including disease outbreaks.

CDC. Vibrio illnesses after Hurricane Katrina — multiple states, August-September 2005. MMWR Morb Mortal Wkly Rep. 2005;54(37):928-31.
CDC. Aeromonas wound infections associated with outdoor activities — California. MMWR Morb Mortal Wkly Rep. 1990;39(20):334-5, 341.

Listed below are reports related to other illnesses, including disease outbreaks, swimming safety, and pool operation.

CDC. Notes from the field: Investigation of leptospirosis underreporting — Puerto Rico, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(22):421.
Reisen W, Takahashi RM, Carroll BD, Quiring R. Delinquent mortgages, neglected swimming pools, and West Nile Virus, California. Emerg Infect Dis. 2008;14(11):1747-9.
CDC. Brief Report: Leptospirosis after flooding of a university campus — Hawaii, 2004. MMWR Morb Mortal Wkly Rep. 2006;55(05):125-7.
CDC. Update: Leptospirosis and unexplained acute febrile illness among athletes participating in triathlons — Illinois and Wisconsin, 1998. MMWR Morb Mortal Wkly Rep. 1998;47(32):673-6.
CDC. Outbreak of acute febrile illness among athletes participating in triathlons — Wisconsin and Illinois, 1998. MMWR Morb Mortal Wkly Rep. 1998;47(28):585-8.

Listed below are reports related to swimming pool operation and disinfection.

Hlavsa MC, Gerth TR, Collier SA, Dunbar ER, Rao G, Epperson G, Bramlett B, Ludwig DF, Gomez D, Stansbury MM, Miller F, Warren J, Nichol J, Bowman H, Huynh B, Loewe KM, Vincent B, Tarrier AL, Shay T, Wright R, Brown AC, Kunz JM, Fullerton KE, Cope JR, Beach MJ. Immediate closures and violations identified during routine inspections of public aquatic facilities — Network for Aquatic Facility Inspection Surveillance, five states, 2013. MMWR Surveill Summ. 2016;65(No. SS-5):1–26.
CDC. Microbes in pool filter backwash as evidence of the need for improved swimmer hygiene — metro-Atlanta, Georgia, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(19):385-88.
CDC. Violations identified from routine swimming pool inspections — selected states and counties, United States, 2008. MMWR Morb Mortal Wkly Rep. 2010;59(19):582-7.
Buss BF, Safranek TJ, Magri JM, Török TJ, Beach MJ, Foley BP. Association between swimming pool operator certification and reduced pool chemistry violations—Nebraska, 2005–2006. J Environ Health 2009;71:36–40.
Vyles T. Growth and evolution of a municipal pool safety and inspection program. J Environ Health 2009;71:40–4.
Shields JM, Gleim ER, Beach MJ. Prevalence of Cryptosporidium spp. and Giardia intestinalis in swimming pools, Atlanta, Georgia. Emerg Infect Dis. 2008;14(6):948-50.
CDC. Notice to readers: Revised recommendations for responding to fecal accidents in disinfected swimming venues. MMWR Morb Mortal Wkly Rep. 2008;57(06):151-2.
CDC. Surveillance data from public spa inspections — United States, May-September 2002. MMWR Morb Mortal Wkly Rep. 2004;53(25):553-5.
CDC. Guidelines for environmental infection control in health-care facilities (hydrotherapy pools and tanks). [PDF – 48 pages] MMWR Morb Mortal Wkly Rep. 2003;52(RR-10):1-44 (see page 20 of this MMWR Recommendations and Reports article).
CDC. Surveillance data from swimming pool inspections — selected states and counties, United States, May-September 2002. MMWR Morb Mortal Wkly Rep. 2003;52(22):513-6.
CDC. Notice to readers: Responding to fecal accidents in disinfected swimming venues. MMWR Morb Mortal Wkly Rep. 2001;50(20):416-7.
CDC. Prevalence of parasites in fecal material from chlorinated swimming pools — United States, 1999. MMWR Morb Mortal Wkly Rep. 2001;50(20):410-2.
Carpenter C, Fayer R, Trout J, Beach MJ. Chlorine disinfection of recreational water for Cryptosporidium parvum. Emerg. Infect Dis. 1999;5(4):579-84.
Karch KM. Application of a data processing system to a swimming pool inspection program. Public Health Rep. 1965;80:211–9.

Listed below are reports related to microbial testing and disinfection.

CDC. Microbes in pool filter backwash as evidence of the need for improved swimmer hygiene — metro-Atlanta, Georgia, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(19):385-88.
CDC. Notice to readers: Revised recommendations for responding to fecal accidents in disinfected swimming venues. MMWR Morb Mortal Wkly Rep. 2008;57(06):151-2.
Shields JM, Gleim ER, Beach MJ. Prevalence of Cryptosporidium spp. and Giardia intestinalis in swimming pools, Atlanta, Georgia. Emerg Infect Dis. 2008;14(6):948-50.
CDC. Notice to readers: Responding to fecal accidents in disinfected swimming venues. MMWR Morb Mortal Wkly Rep. 2001;50(20):416-7.
CDC. Prevalence of parasites in fecal material from chlorinated swimming pools — United States, 1999. MMWR Morb Mortal Wkly Rep. 2001;50(20):410-2.
Carpenter C, Fayer R, Trout J, Beach MJ. Chlorine disinfection of recreational water for Cryptosporidium parvum. Emerg. Infect Dis. 1999;5(4):579-84.

Listed below are reports related to swimming pool chemicals.

Hlavsa M, Laco J, Hill V. Good pool chemistry keeps swimming healthy and safe. [PDF – 3 pages] J Environ Health. 2019;81(9):32-4.
Wilken JA, DiMaggio M, Kaufmann M, O’Connor K, Smorodinsky, S, Armatas C, Barreau T, Kreutzer R, Ancheta L. Inhalational chlorine injuries at public aquatic venues — California, 2008–2015. MMWR Morb Mortal Wkly Rep. 2017;66:498–501.
Anderson AR, Welles WL, Drew J, Orr MF. The distribution and public health consequences of releases of chemicals intended for pool use in 17 states, 2001-2009. J Environ Health. 2014;76(9):10-5.
Hlavsa MC, Robinson TJ, Collier SA, Beach MJ. Pool chemical–associated health events in public and residential settings — United States, 2003–2012, and Minnesota, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(19):427-30.
CDC. Acute illness and injury from swimming pool disinfectants and other chemicals — United States, 2002-2008. MMWR Morb Mortal Wkly Rep. 2011;60(39):1343-7.
CDC. Pool chemical–associated health events in public and residential settings — United States, 1983–2007. MMWR Morb Mortal Wkly Rep. 2009;58(18):489-93.
Weisel CP, Richardson SD, Nemery B, Aggazzotti G, Baraldi E, Blatchley III ER, Blount BC, Carlsen KH, Eggleston PA, Frimmel FH, Goodman M, Gordon G, Grinshpun SA, Heederik D, Kogevinas M, LaKind JS, Nieuwenhuijsen MJ, Piper FC, Sattar SA. Childhood asthma and environmental exposures at swimming pools: state of the science and research recommendations. Environ. Health Perspect. 2009; Apr 117(4):500-7.
CDC. Respiratory and ocular symptoms among employees of a hotel indoor waterpark resort — Ohio, 2007. MMWR Morb Mortal Wkly Rep. 2009;58(4):81-85.
Chen L, Dang B, Mueller C, Dunn KH, Almaguer D, Ernst JL, Otto III CS. Health hazard evaluation report: investigation of employee symptoms at an indoor waterpark — Ohio, 2007. [PDF – 64 pages] National Institute for Occupational Safety and Health. 2008; June: HETA 2007-0163-3062.
CDC. Ocular and respiratory illness associated with an indoor swimming pool — Nebraska, 2006. MMWR Morb Mortal Wkly Rep. 2007;56(36):929-932.
CDC. Erosion of dental enamel among competitive swimmers — Virginia. MMWR Morb Mortal Wkly Rep. 1983;32(28):361-2.

Listed below are reports related to injuries and outdoor health.

Gilchrist J, Parker EM. Racial/ethnic disparities in fatal unintentional drowning among persons aged ≤29 Years — United States, 1999–2010. MMWR Morb Mortal Wkly Rep. 2014;63(19):421-6.
Hlavsa MC, Robinson TJ, Collier SA, Beach MJ. Pool chemical–associated health events in public and residential settings — United States, 2003–2012, and Minnesota, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(19):427-30.
CDC. Drowning — United States, 2005–2009. MMWR Morb Mortal Wkly Rep. 2012;61(19):344-7.
CDC. Sunburn and sun protective behaviors among adults aged 18–29 years — United States, 2000–2010. MMWR Morb Mortal Wkly Rep. 2012;61(18):317–22.
CDC. Acute illness and injury from swimming pool disinfectants and other chemicals — United States, 2002-2008. MMWR Morb Mortal Wkly Rep. 2011;60(39):1343-7.
CDC. Pool Chemical–associated health events in public and residential settings — United States, 1983-2007.MMWR Morb Mortal Wkly Rep. 2009;58(18):489-93.
CDC. Sunburn prevalence among adults — United States, 1999, 2003, and 2004. MMWR Morb Mortal Wkly Rep. 2007;56(21):524-8.
CDC. Nonfatal and fatal drownings in recreational water settings — United States, 2001-2002. MMWR Morb Mortal Wkly Rep. 2004;53(21):447-52.
CDC. Drownings in a private lake — North Carolina, 1981-1990. MMWR Morb Mortal Wkly Rep. 1992;41(19):329-31.
CDC. Child drownings and near drownings associated with swimming pools — Maricopa County, Arizona 1988 and 1989. MMWR Morb Mortal Wkly Rep. 1990;39(26):441-2.
CDC. Epidemiologic notes and report diving-associated spinal cord injuries during drought conditions — Wisconsin, 1988. MMWR Morb Mortal Wkly Rep. 1988;37(30):453-4.
CDC. Injuries at a water slide — Washington. MMWR Morb Mortal Wkly Rep. 1984;33(27):379-82,387.
CDC. Perspectives in disease prevention and health promotion aquatic deaths and injuries — United States. MMWR Morb Mortal Wkly Rep. 1982;31(31):417-9.

Listed below are reports related to international recreational water.

Morgan OW, Brunette G, Kapella BK, McAuliffe I, Katongole-Mbidde E, Li W, Marano N, Okware S, Olsen SJ, Secor WE, Tappero JW, Wilkins PP, Montgomery SP. Schistosomiasis among recreational users of upper Nile river, Uganda, 2007. Emerg Infect Dis. 2010;16(5):866-8.
Amilasan AT, Ujiie M, Suzuki M, Salva, E, Belo MCP, Koizumi N, Yoshimatsu K, Schmidt WP, Marte S, Dimaano EM, Villarama JB, Ariyoshi K. Outbreak of leptospirosis after flood, the Philippines, 2009. Emerg Infect Dis. 2012;18(1):91-4.
Cogo PE, Scagli M, Gatti S, Rossetti F, Alaggio R, Laverda AM, Zhou L, Xiao L, Visvesvara GS. Fatal Naegleria fowleri meningoencephalitis, Italy. Emerg Infect Dis. 2004:10(10):1835-7.
Sejvar J, Bancroft Em Winthrop K, Bettinger J, Bajani M, Bragg S, Shutt K, Kaiser R, Marano N, Popovic T, Tappero J, Ashford D, Mascola L, Vugia D, Perkins B, Rosenstein N, Eco-Challenge Investigation Team. Leptospirosis in “Eco-Challenge” athletes, Malaysian Borneo, 2000. Emerg Infect Dis. 2003;9(6):702-7.
CDC. Update: Outbreak of acute febrile illness among athletes participating in Eco-Challenge-Sabah 2000 — Borneo, Malaysia, 2000. MMWR Morb Mortal Wkly Rep. 2001;50(02):21-4.
CDC. Public health dispatch: outbreak of acute febrile illness among participants in Eco-Challenge Sabah 2000 — Borneo, Malaysia, 2000. MMWR Morb Mortal Wkly Rep. 2000;49(36):816-7.
CDC. Outbreak of leptospirosis among white-water rafters — Costa Rica, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(25):577-9.
CDC. Schistosomiasis in U.S. Peace Corps volunteers — Malawi, 1992. MMWR Morb Mortal Wkly Rep. 1993;42(29):565-70.
CDC. Acute schistosomiasis in U.S. travelers returning from Africa. MMWR Morb Mortal Wkly Rep. 1990;39(9):141-2,147-8.
CDC. Acute schistosomiasis with transverse myelitis in American students returning from Kenya. MMWR Morb Mortal Wkly Rep. 1984;33(31):445-7.
CDC. Schistosomiasis among river rafters — Ethiopia. MMWR Morb Mortal Wkly Rep. 1983;32(44):585-6.
CDC. Cercarial dermatitis among bathers in California: Katayama Syndrome among travelers to Ethiopia. MMWR Morb Mortal Wkly Rep. 1982;31(32):435-8.

Listed below are reports related to international RWIs and behavioral science.

CDC. Microbes in pool filter backwash as evidence of the need for improved swimmer hygiene — Metro-Atlanta, Georgia, 2012. MMWR Morb Mortal Wkly Rep. 2013;62(19):385-88.
CDC. Promotion of healthy swimming after a statewide outbreak of cryptosporidiosis associated with recreational water venues — Utah, 2008–2009. MMWR Morb Mortal Wkly Rep. 2012;61(19):348-52.
McClain J, Bernhardt JM, Beach MJ. Assessing parents’ perception of children’s risk for recreational water illnesses. Emerg Infect Dis. 2005;11(5):670-6.

These manuals were developed by CDC during the 1950s, 1960s, 1970s and early 1980s. Much of the information in the manuals may still be helpful to aquatics staff, designers, and public health professionals. However, CDC’s Healthy Swimming and Model Aquatic Health Code websites have the most current information on water quality, disinfection, and operation for aquatic venues, thus superseding information found in these earlier manuals.

Suggested Health and Safety Guidelines for Recreational Water Slide Flumes (July 1981)

Message: Guidance to assist state and local health agencies develop practical water slide slume safety and health regulations.
Audience: State and local health agencies.

Document:

Suggested Health and Safety Guidelines for Public Spas and Hot Tubs (April 1981, Revised January 1985)

Message: Guidance to assist state and local health agencies develop practical spa and hot tub safety and health regulations.
Audience: State and local health agencies.

Document:

Swimming Pools: Safety and Disease Control through Proper Design and Operation (June 1976, Reprinted March 1988)

Message: Information on design, construction, operation, maintenance, and the effect of each on disease control practices and safety procedures.
Audience: State and local health agencies.

Document:

Swimming Pools: Safety and Disease Control through Proper Design and Operation (June 1976, Reprinted March 1988) [PDF – 110 pages]

Swimming Pools and Natural Bathing Places: An Annotated Bibliography (1957-1966)

Message: Construction and operation of swimming pools and outdoor bathing places.
Audience: State and local health agencies.

Document:

Swimming Pools and Natural Bathing Places: An Annotated Bibliography (1957-1966) [PDF – 61 pages]

Swimming Pools: Disease Control Through Proper Design and Operation (July 1959)

Message: Guidance for the proper construction, operation, and maintenance of public swimming pools.
Audience: State and local health agencies.

Document:

Swimming Pools: Disease Control Through Proper Design and Operation (July 1959) [PDF – 156 pages]

Fast Facts

In the United States during 2009, there were approximately 301 million swimming visits each year by persons over the age of six ¹.
Thirty-six percent of children aged 7-17 years, and 15% of adults in the United States, swim at least six times per year ¹.
Swimming is the fourth most popular recreational activity in the United States ¹.
Swimming is the most popular recreational activity for children and teens (ages 7-17) ¹.
About 91 million people over the age of 16 swim in oceans, lakes, and rivers each year in the United States ².

Almost 1 in 8 (12.1% or 13,532 of 111,487) routine pool inspections conducted during 2008 identified serious violations that threatened public health and safety and resulted in an immediate closure ⁴.
More than 1 in 10 (10.7% or 12,917 of 120,975) routine pool inspections identified pool disinfectant level violations. Chlorine and other pool disinfectants are the primary barrier to the spread of germs in the water in which we swim ⁴.
About half (56.8%) of spas are in violation of local environmental health ordinances, and about 1 in 9 spas require immediate closure (11%) ⁶.

A total of 81 recreational water–associated outbreaks affecting at least 1,326 persons were reported to CDC for 2009-2010 ⁷.
Cryptosporidium (or Crypto) is an extremely chlorine-tolerant parasite that can survive in a properly chlorinated pool for 3.5–10.6 days ⁸.
Of 49 recreational water–associated outbreaks of gastroenteritis during 2009-2010, 55% were caused by Crypto ⁷.
Of 57 gastroenteritis outbreaks associated with treated (for example, chlorinated) recreational water venues, 84% were caused by Crypto ⁷.
More than 1 in 5 (21.6%) of American adults do not know swimming while ill with diarrhea can heavily contaminate water in which we swim and make other swimmers sick ⁹.

In 2008, almost 4,600 persons visited an emergency department for pool chemical-associated injuries. The most common injury diagnoses were poisoning, which includes ingestion of pool chemicals as well as inhalation of vapor, fumes, or gases and dermatitis/conjunctivitis. More than half of the injuries occurred at a residence ⁷.
Drowning is the leading cause of unintentional injury death among children aged 1–4 years. Drowning is the second leading cause of unintentional injury death among children 5–9 years ¹⁰.
More than 60% of fatal drownings of 0–4 year-olds occur in swimming pools ¹¹.
In the United States in 2009, almost 24 million individuals participated in motor or power boat activities ¹.
In 2010, 3,153 persons were injured and 672 died in recreational boating accidents ¹².
Of those who drowned in a boating accident, 88% were reported to not be wearing a life jacket ¹³.

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Hubbard R. U.S. Hot tub sales not so hot in 2007. Pool and Spa Marketing. March (2009b):14.
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Shields JM, Hill VR, Arrowood MJ, Beach MJ. Inactivation of Cryptosporidium parvum under chlorinated recreational water conditions. J Water Health 2008;6(4):513–20.
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Boating Safety Resource Center. Recreational boating statistics 2010 [PDF – 77 pages]. United States Coast Guard. 2011.

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Page last reviewed: June 2, 2021

Content source: Centers for Disease Control and Prevention